A.E. Khoury

Laparoscopic dismembered pyeloplasty by a retroperitoneal approach in children

To report our experience with dismembered laparoscopic pyeloplasty by a retroperitoneal approach in children with pelvi‐ureteric junction (PUJ) obstruction.

Retroperitoneal laparoscopic vs open partial nephroureterectomy in children.

To compare the results of retroperitoneal laparoscopic with open partial nephroureterectomy.

Extravesical Nondismembered Ureteroplasty with Detrusorrhaphy: A Renewed Technique to Correct Vesicoureteral Reflux in Children

We performed an extravesical nondismembered reimplant to correct surgically primary vesicoureteral reflux in 45 patients (65 renal units) between April 1989 and September 1990. Of the units 6 had grade I reflux, 16 grade II, 23 grade III, 14 grade IV and 6 grade V. Only patients with primary reflux were included in this study. The success rate was 100% for grades I to III, 92.9% for grade IV and 66.7% for grade V. Overall, the reflux was cured in 62 of the 65 operated renal units (95.4%) or 95.6% of the patients (43 of 45). Postoperative morbidity and complications were minimal. No cases of postoperative obstruction were detected on excretory urography 6 weeks postoperatively. Seven children (16%) suffered from transient inadequate bladder emptying as assessed by post-void ultrasound residual evaluations. This problem resolved spontaneously after a maximum of 4 weeks of clean intermittent catheterization. Compared to conventional transvesical technique, the discomfort related to bladder spasms during the postoperative period was subjectively decreased and patients had no prolonged hematuria.

The use of tolterodine in children after oxybutynin failure

To assess the safety and efficacy of tolterodine tartrate prescribed to children who previously failed to tolerate oxybutynin chloride.

Submucosal Injection of Polyvinyl Alcohol Foam in Rabbit Bladder

Submucosal injection of either polytetrafluoroethylene (Teflon) or collagen has been used in the treatment of vesicoureteral reflux. Although the methods and principles of this treatment are effective, there are concerns regarding the safety and long-term effectiveness of these substances. We present a pilot study to explore the potential of an alternate substance (polyvinyl alcohol foam) for this treatment. Polyvinyl alcohol foam (Ivalon) particles measuring 150 to 250 mu. were injected submucosally into the bladder of New Zealand white rabbits. The bladder was examined macroscopically and microscopically at 1 and 2 weeks, and 1, 2 and 3 months after the injection. The particles created a raised lesion under the mucosa that was visible to the naked eye as late as 3 months after the submucosal injection. The particles remained in a submucosal location after 3 months. At 1 week after injection there was a foreign body giant cell response to the particles. At 3 months the giant cell response persisted and the particles were surrounded by a fibrotic reaction. There was little inflammatory response otherwise. These preliminary results indicate that polyvinyl alcohol foam may be suitable for subureteral injection in the treatment of vesicoureteral reflux.

Iliac Osteotomy: A Model to Compare the Options in Bladder and Cloacal Exstrophy Reconstruction

Bladder exstrophy and cloacal exstrophy present challenging reconstructive problems. Traditionally, bilateral posterior iliac osteotomy has been performed in the majority of patients undergoing primary closure for these abnormalities. Recently, 2 anterior osteotomy approaches have been proposed: 1) incision of the ilium transversely above the acetabulum (transverse osteotomy) and 2) incision of the superior ramus of the pubis (superior ramus osteotomy). We devised a new anterior mid-iliac diagonal osteotomy that provides a more functional pelvic closure. To provide a fair comparison of the procedures we developed a pelvic exstrophy model based on data from a 3-dimensional computerized tomogram of a 3-year-old patient with classical bladder exstrophy. The different osteotomies were then performed on the model and the results were compared. Our new anterior mid-iliac diagonal osteotomy correction allowed the best surgical approach, provided the best correction of the flattened ilia bony deformities, was performed in the thinnest area of marrow bone and resulted in the best pelvic symmetry.

Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning

Minimally invasive surgery is not exclusive to the treatment of adult conditions. It has also been used in paediatric urology, and the authors from Toronto and Paris describe a mentorship‐training model for laparoscopic retroperitoneal surgery. They confirmed that a mentored approach is the way to develop this procedure. They also found that ablative procedures are learned relatively early, but that reconstructive procedures require a high degree of skill in laparoscopic techniques, requiring formal training focusing mainly on suturing techniques.

URETHRAL REPLACEMENT WITH VASCULARIZED TUNICA VAGINALIS: DEFINING THE OPTIMAL FORM OF USE

PURPOSE Residual urethral defects after failed hypospadias surgery present difficulties in reconstruction. In these situations, repair using vascularized tissue flaps remains ideal, yet challenging. In order to offer more surgical alternatives in these cases, the use of vascularized tunica vaginalis flaps as urethral replacements has recently been established in an animal model. We undertook the following studies to further define the role of tunica vaginalis in urethral reconstruction. MATERIALS AND METHODS A vascularized flap of tunica vaginalis was used to replace an experimentally created 25-30 mm. gap in the anterior urethra of 26 rabbits, either as an onlay or tube flap. A control group consisting of 7 animals underwent only a segmental anterior urethral resection and primary re-anastomosis. RESULTS Satisfactory urethral healing occurred in all control animals that survived the procedure. All 8 animals which had tunica vaginalis tube flap reconstruction underwent contracture of the neourethra probably secondary to the presence of striated cremasteric muscle elements brought with the tunica during mobilization. All 16 animals available for long term study in the onlay flap group had excellent flap viability and 100% urethral patency rates. The mesothelial lining of the tunica was seen to be replaced by a stratified epithelial lining similar to the urothelial lining of the native urethra. CONCLUSION The tunica vaginalis is a viable alternative to other tissues presently used for urethral replacement and can be used successfully as a vascularized onlay flap.

Ventriculoperitoneal shunt infection after augmentation cystoplasty

PURPOSE We characterized the occurrence of ventriculoperitoneal shunt infections after augmentation cystoplasty. MATERIALS AND METHODS We reviewed the records of 20 myelodysplastic children with ventriculoperitoneal shunts followed for a minimum of 12 months after augmentation. RESULTS In 4 children (20%) a ventriculoperitoneal shunt infection developed. The single gram-positive infection occurred early (less than 30 days). The 3 gram-negative infections were delayed presentations (greater than 30 days). Organisms in 2 of the 3 gram-negative infections had been noted in a preoperative urine culture. CONCLUSIONS Ventriculoperitoneal shunt infection after bladder augmentation is common. Delayed presentation of shunt infections may indicate gram-negative infection. Sterilization of the urinary tract is indicated before augmentation.

Healing of unstented tubularized incised plate urethroplasty: an experimental study in a rabbit model

To develop a rabbit model to study the temporal healing taking place after an unstented tubularized incised plate urethroplasty (TIPU).